Memorial Community Hospital & Health System

“SURGICAL SERVICES CFR(s): If a CAH provides surgical services, surgical procedures must be performed in a safe manner by qualified practitioners who have been granted clinical privileges by the governing body, or responsible individual, of the CAH in accordance with the designation requirements under paragraph (a) of this section. This Condition is not met as evidenced by: 52353 Based on observations and interviews, the Critical Access Hospital (CAH) failed to ensure that outdated supplies were removed for use in Operating Room 1 Anesthesia cart, Operating Room 2 Anesthesia cart, the anesthesia work room and surgical supply room. This failed practice has the potential to affect all patients receiving care in the surgical services department. The CAH reported 353 surgical cases during the 2023 fiscal year. This resulted in the Condition of Participation for Surgical Services not being met. Findings are: A. Observations during the surgical department tour (4/9/2025 from 12:30 PM to 2:30 PM) with Surgical Manager RN (Registered Nurse) revealed in Operating Room 1 the anesthesia cart to have the following expired and/or opened items available patient for use: -3 BD (Becton, Dickinson and Company) Whitacre (type of needle) 25 gauge needles (a needle used to deliver medications in the spinal space) expired on 2/21; -1 BD Whitacre 25 gauge needle expired on 2/29/24; -6 BD Whitacre 25 gauge needles expired on 7/31/24; -2 Touhy (type of needle) epidural 18 gauge needles (a needle to deliver medications in the spinal space) expired on 4/20/20; -1 Touhy epidural 18 gauge needle expired on 8/31/24; -2 Pencan pencil point (type of needle) 24-gauge spinal needles (a needle to deliver medications in the spinal space) expired on 5/31/23; -1 Pencan pencil point 24 gauge spinal needle expired on 5/18/23; -1 Endotracheal tube (a breathing tube inserted in the windpipe to help provide oxygen) expired on 9/20; -2 Endotracheal tubes expired on 4/25/22; -6 Endotracheal tubes expired on 1/1/23; -2 Endotracheal tubes expired on 2/25/24; -1 Endotracheal tube expired on 3/5/23, seal broken with open packaging; -1 Endotracheal tube expired on 2/4/24, seal broken with open packaging; and -1 Endotracheal tube, seal broken with open packaging. B. Observations during the surgical department tour (4/9/2025 from 12:30 PM to 2:30 PM) with Surgical Manager Registered Nurse (RN) revealed in Operating Room 2 the anesthesia cart to have the following expired and/or opened items available patient for use: -4 Pencan pencil point 24 gauge spinal needles expired on 5/31/23; -2 Touhy epidural 18 gauge needles expired on 4/30/20; -1 Touhy epidural 18 gauge needle expired on 2/21; -2 Tuohy epidural 18 gauge needles expired on 4/30/20; -1 Tuohy epidural 18 gauge needle expired on 6/30/24; and -1 Endotracheal tube expired on 2/4/24, seal broken with opened packaging. C. Observations during the tour of the surgical supply room (4/9/2025 from 12:30 PM to 2:30 PM) revealed expired supplies available for patient use: - 25 packages sterile cast padding (used to protect the skin beneath a cast) expired on 3/28/25. D. Observations during the tour of the Anesthesia work room (4/9/2025 from 12:30 PM to 2:30 PM) revealed expired supply available for patient use: -Mastisol adhesive liquid medical adhesive (used for to secure dressings) expired on 2/23. E. Interview with Surgical Manager RN (4/9/2025 at 1:00PM) confirmed the above expired and opened packages were available for patient use in the anesthesia cart in Operating Room 1. Also stated “nursing is not responsible for these carts; these are anesthesia’s responsibility.” -Interview with Surgical Manager RN (4/9/2025 at 1:15PM) confirmed the above expired and opened packages were available for patient use in the anesthesia cart in Operating Room 2. -Interview with Surgical Manager RN (4/9/2025 at 1:40 PM) confirmed the above box of sterile cast padding packages were expired and available for patient use. -Interview with CRNA-A (Certified Nurse Anesthetist) (4/9/2025 at 2:00PM) confirmed the above expired supply in the anesthesia work room was available for patient use.”

“COMP ASSESSMENT, CARE PLAN & DISCHARGE CFR(s): §485.645(d)(5) Comprehensive assessment, comprehensive care plan, and discharge planning (§483.20(b), and §483.21(b) and (c)(2) of this chapter), except that the CAH is not required to use the resident assessment instrument (RAI) specified by the State that is required under §483.20(b), or to comply with the requirements for frequency, scope, and number of assessments prescribed in §413.343(b) of this chapter). “ §483.20(b) Comprehensive assessments- (1) Resident assessment instrument. A facility must make a comprehensive assessment of a resident’s needs, strengths, goals, life history and preferences, using the resident assessment instrument (RAI) specified by CMS. The assessment must include at least the following: (i) Identification and demographic information. (ii) Customary routine. (iii) Cognitive patterns. (iv) Communication. (v) Vision. (vi) Mood and behavior patterns. (vii) Psychosocial well-being. (viii) Physical functioning and structural problems. (ix) Continence. (x) Disease diagnoses and health conditions. (xi) Dental and nutritional status. (xii) Skin condition. (xiii) Activity pursuit. (xiv) Medications. (xv) Special treatments and procedures. (xvi) Discharge planning. (xvii) Documentation of summary information regarding the additional assessment performed on the care areas triggered by the completion of the Minimum Data Set (MDS). (xviii) Documentation of participation in assessment. The assessment process must include direct observation and communication with the resident, as well as communication with licensed and nonlicensed direct care staff members on all shifts. (2) When required. Subject to the timeframes prescribed in §413.343(b) of this chapter, a facility must conduct a comprehensive assessment of a resident in accordance with the timeframes specified in paragraphs (b)(2) (i) through (iii) of this section. The timeframes prescribed in §413.343(b) of this chapter do not apply to CAHs. (i) Within 14 calendar days after admission, excluding readmissions in which there is no significant change in the resident’s physical or mental condition. (For purposes of this section, “readmission” means a return to the facility following a temporary absence for hospitalization or for therapeutic leave.) (ii) Within 14 calendar days after the facility determines, or should have determined, that there has been a significant change in the resident’s physical or mental condition. (For purposes of this section, a “significant change” means a major decline or improvement in the resident’s status that will not normally resolve itself without further intervention by staff or by implementing standard disease-related clinical interventions, that has an impact on more than one area of the resident’s health status, and requires interdisciplinary review or revision of the care plan, or both.) (iii) Not less often than once every 12 months. “ §483.21(b) Comprehensive care plans. (1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident’s medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following: (i) The services that are to be furnished to attain or maintain the resident’s highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25, or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25, or §483.40 but are not provided due to the resident’s exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (i) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident’s medical record. (ii) In consultation with the resident and the resident’s representative(s)- (A) The resident’s goals for admission and desired outcomes. (B) The resident’s preference and potential for future discharge. Facilities must document whether the resident’s desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. (2) A comprehensive care plan must be- (i) Developed within 7 days after completion of the comprehensive assessment. (ii) Prepared by an interdisciplinary team, that includes but is not limited to- (A) The attending physician. (B) A registered nurse with responsibility for the resident. (C) A nurse aide with responsibility for the resident. (D) A member of food and nutrition services staff. (E) To the extent practicable, the participation of the resident and the resident’s representative(s). An explanation must be included in a resident’s medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident’s care plan. (F) Other appropriate staff or professionals in disciplines as determined by the resident’s needs or as requested by the resident. (iii) Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. (3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must- (i) Meet professional standards of quality. (ii) Be provided by qualified persons in accordance with each resident’s written plan of care. (iii) Be culturally-competent and trauma-informed. “ §483.21(c)(2) Discharge summary. When the facility anticipates discharge a resident must have a discharge summary that includes, but is not limited to, the following: (i) A recapitulation of the resident’s stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results. (ii) A final summary of the resident’s status to include items in paragraph (b)(1) of §483.20, at the time of the discharge that is available for release to authorized persons and agencies, with the consent of the resident or resident’s representative. (iii) Reconciliation of all pre-discharge medications with the resident’s post-discharge medications (both prescribed and over-the-counter). (iv) A post-discharge plan of care that is developed with the participation of the resident and, with the resident’s consent, the resident representative(s), which will assist the resident to adjust to his or her new living environment. The post-discharge plan of care must indicate where the individual plans to reside, any arrangements that have been made for the resident’s follow up care and any post-discharge medical and non-medical services. This Standard is not met as evidenced by: 46123 Based on medical record review, facility policy review and staff interview the Critical Access Hospital (CAH) failed to ensure a comprehensive assessment within 14 calendar days after admission for 4 of 4 swing bed patients (Patients 32, 33, 34 and 36) and a discharge summary that included a recapitulation of the patients stay for 4 of 4 swing bed patients (Patients 33, 34, 35 and 36). This failed practice had the potential to affect all swing bed patients at the CAH. The number of swing bed patients at the CAH for Fiscal Year 2023 was 187. Findings are: A. Review of Patient 32’s medical record (4/10/25 at 12:30PM) revealed a swing bed admission of 3/24/25 - currently remains swing bed patient for a vertebral fracture (a bone that makes up the spine has a break). Review of the entire medical record revealed a lack of evidence of a comprehensive assessment within 14 calendar days after admission -- Review of Patient 33’s medical record (4/10/25 at 12:45PM) revealed a swing bed admission of 2/21/25 - 3/10/25 for a gastrointestinal bleed (any bleeding that originates within the digestive tract, encompassing a wide range of potential causes and symptoms). Review of the entire medical record revealed a lack of evidence a comprehensive assessment within 14 calendar days after admission and evidence of a discharge summary that included a recapitulation of the patients stay. - Review of Patient 34’s medical record (4/10/25 at 1:05PM) revealed a swing bed admission of 11/22/24 - 12/16/24 for osteomyelitis (a bone infection). Review of the entire medical record revealed a lack of evidence of a comprehensive assessment within 14 calendar days after admission and evidence of a discharge summary that included a recapitulation of the patients stay. - Review of Patient 35’s medical record (4/10/25 at 1:30PM) revealed a swing bed admission of 12/2/24 - 12/14/24 for a bowel obstruction (occurs when food or liquid can’t move through the intestines due to a blockage). Review of the entire medical record revealed a lack of evidence of a discharge summary that included a recapitulation of the patients stay. - Review of Patient 36’s medical record (4/10/25 at 2:06PM) revealed a swing bed admission of 12/10/24 - 12/26/24 for gangrene (a serious medical condition characterized by the death of tissue, typically due to a lack of blood supply or a serious bacterial infection). Review of the entire medical record revealed a lack of evidence of a comprehensive assessment within 14 calendar days after admission and evidence of a discharge summary that included a recapitulation of the patients stay. B. Review of facility policy Scope Of Services Level Of Care Provided in Skilled Care Swing Beds, last approved 4/2023 revealed, all swing bed patients will have a discharge summary that includes the following information: Summary (recapitulation) of the patients stay. A final summary of the patient status at the time of discharge is available to authorized persons and agencies with the consent of the patient or their legal representative. A post discharge plan of care that is developed with the participation of the patient and his or her family, which will assist the patient to adjust to his or her living environment. The policy lacks information regarding a comprehensive assessment being completed within 14 days of admission to swing bed. C. Interview (4/10/2025 at 2:30 PM) with Director of Nursing (DON) confirmed the medical records lacked evidence of the comprehensive assessment and a discharge summary with a recapitulation of the patients stay .”

“Hospital CAH and LTC Emergency Power CFR(s): §482.15(e) Condition for Participation: (e) Emergency and standby power systems. The hospital must implement emergency and standby power systems based on the emergency plan set forth in paragraph (a) of this section and in the policies and procedures plan set forth in paragraphs (b)(1)(i) and (ii) of this section. §483.73(e), §485.625(e), §485.542(e) (e) Emergency and standby power systems. The [LTC facility CAH and REH] must implement emergency and standby power systems based on the emergency plan set forth in paragraph (a) of this section. §482.15(e)(1), §483.73(e)(1), §485.542(e)(1), §485.625(e)(1) Emergency generator location. The generator must be located in accordance with the location requirements found in the Health Care Facilities Code (NFPA 99 and Tentative Interim Amendments TIA 12-2, TIA 12-3, TIA 12-4, TIA 12-5, and TIA 12-6), Life Safety Code (NFPA 101 and Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4), and NFPA 110, when a new structure is built or when an existing structure or building is renovated. 482.15(e)(2), §483.73(e)(2), §485.625(e)(2), §485.542(e)(2) Emergency generator inspection and testing. The [hospital, CAH and LTC facility] must implement the emergency power system inspection, testing, and [maintenance] requirements found in the Health Care Facilities Code, NFPA 110, and Life Safety Code. 482.15(e)(3), §483.73(e)(3), §485.625(e)(3),§485.542(e)(2) Emergency generator fuel. [Hospitals, CAHs and LTC facilities] that maintain an onsite fuel source to power emergency generators must have a plan for how it will keep emergency power systems operational during the emergency, unless it evacuates. *[For hospitals at §482.15(h), LTC at §483.73(g), REHs at §485.542(g), and and CAHs §485.625(g):] The standards incorporated by reference in this section are approved for incorporation by reference by the Director of the Office of the Federal Register in accordance with 5 U.S.C. 552(a) and 1 CFR part 51. You may obtain the material from the sources listed below. You may inspect a copy at the CMS Information Resource Center, 7500 Security Boulevard, Baltimore, MD or at the National Archives and Records Administration (NARA). For information on the availability of this material at NARA, call 202-741-6030, or go to: http://www.archives.gov/federal_register/code_of_federal_regulations/ibr_locations.html. If any changes in this edition of the Code are incorporated by reference, CMS will publish a document in the Federal Register to announce the changes. (1) National Fire Protection Association, 1 Batterymarch Park, Quincy, MA 02169, www.nfpa.org, 1.617.770.3000. (i) NFPA 99, Health Care Facilities Code, 2012 edition, issued August 11, 2011. (ii) Technical interim amendment (TIA) 12-2 to NFPA 99, issued August 11, 2011. (iii) TIA 12-3 to NFPA 99, issued August 9, 2012. (iv) TIA 12-4 to NFPA 99, issued March 7, 2013. (v) TIA 12-5 to NFPA 99, issued August 1, 2013. (vi) TIA 12-6 to NFPA 99, issued March 3, 2014. (vii) NFPA 101, Life Safety Code, 2012 edition, issued August 11, 2011. (viii) TIA 12-1 to NFPA 101, issued August 11, 2011. (ix) TIA 12-2 to NFPA 101, issued October 30, 2012. (x) TIA 12-3 to NFPA 101, issued October 22, 2013. (xi) TIA 12-4 to NFPA 101, issued October 22, 2013. (xiii) NFPA 110, Standard for Emergency and Standby Power Systems, 2010 edition, including TIAs to chapter 7, issued August 6, 2009.. This Standard is not met as evidenced by: 45508 Based on document review and interview the facility failed to maintain the emergency generator. This deficient practice increases the likelihood of generation equipment malfunction or failure and affects all occupants. Facility census was 14 and licensed for 25. Findings are: Document review on 4/7/2025 at 9:21 am found the facility could not provide documentation for monthly generator testing during the use of a temporary generator, nor an annual inspection or load bank test for the permanent generator. During interview on 4/7/2025 at 9:21 am staff confirmed the lack of documentation.”

“42 CFR 485.623 The facility must meet the applicable provisions of the 2012 Edition of the Life Safety Code of the National Fire Protection Association. This facility is governed by Chapter 19, Existing Health Care Occupancies of the 2012 Edition of the National Fire Protection Association [NFPA], Chapter 101: Life Safety Code. Memorial Community Hospital & Health System received construction approval in 2003. The construction is classified as Type II (222) and includes two stories and a basement. Patients occupy the first and second floors only. Smoke barriers are located each floor. Smoke compartments are located as follows. First floor: Surgery wing, OR wing, Administrative wing, Kitchen wing, ER wing and Radiology wing. Second floor: North wing and South wing. Basement: Med Records wing, Boiler wing and Shell Space wing. There is a two hour fire/smoke barrier on the main level separating the Clinic area from the Health Care occupancy. The building is fully fire sprinkler protected and includes a fire alarm system with smoke detection in all corridors and spaces open to the corridors. The facility has a capacity of 25 and a census of 14 at the time of the survey. Memorial Community Hospital & Health System was found to be not in compliance with the requirements for participation in Medicare/Medicaid at 42 CFR 485.623, Life Safety from Fire, and the related National Fire Protection Association (NFPA) Standard 101 - 2012 edition.”

“Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Fire Alarm System - Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72 This Standard is not met as evidenced by: 45508 Based on document review and interview the facility failed to provide periodic smoke detector sensitivity testing. This deficient practice increases the likelihood of system malfunction or failure and affects all occupants. Facility census was 14 and licensed for 25. Findings are: Document review on 4/7/2025 at 9:34 am found the facility could not provide documentation of a sensitivity test of the fire alarm smoke detectors. During interview on 4/7/2025 at 9:34 am staff confirmed the lack of documentation.”

“Sprinkler System - Installation CFR(s): NFPA 101 Spinkler System - Installation 2012 EXISTING Nursing homes, and hospitals where required by construction type, are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. In Type I and II construction, alternative protection measures are permitted to be substituted for sprinkler protection in specific areas where state or local regulations prohibit sprinklers. In hospitals, sprinklers are not required in clothes closets of patient sleeping rooms where the area of the closet does not exceed 6 square feet and sprinkler coverage covers the closet footprint as required by NFPA 13, Standard for Installation of Sprinkler Systems. 19.3.5.1, 19.3.5.2, 19.3.5.3, 19.3.5.4, 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, 9.7.1.1(1) This Standard is not met as evidenced by: 45508 Based on observation and interview the facility failed to maintain a ceiling membrane to collect heat and activate the fire sprinkler system. This deficient practice increases the likelihood of sprinkler system malfunction or failure affecting all occupants of the facility. Facility census was 14 and licensed for 25. Findings are: Observation between 10:11 am and 10:53 am on 4/7/2025 found missing ceiling tiles in: 1. Both lower level training rooms. 2. RT Blood & Gas office 3. Main Floor EVS Room 4. Clean Utility room by Specialty Nurses Desk During interview on 4/7/2025 between 10:00 and 10:53 am staff confirmed missing or out of place ceiling tiles.”

“Fire Drills CFR(s): NFPA 101 Fire Drills Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms. 19.7.1.4 through 19.7.1.7 This Standard is not met as evidenced by: 45508 Based on document review and interview the facility failed to conduct quarterly fire drills for each shift. This deficient practice increases likelihood of confusion and delayed response from staff affecting all occupants. Facility census was 14 and licensed for 25. Findings are: Document review on 4/7/2025 at 09:15 am found the facility failed to: 1. Conduct a drill in first quarter 2024 for the overnight shift. 2. Conducted 4 of 9 fire drills within an hour of another drill. During interview on 4/7/2025 at 9:15 am staff confirmed the lack of drill and timing of drills.”

“Portable Space Heaters CFR(s): NFPA 101 Portable Space Heaters Portable space heating devices shall be prohibited in all health care occupancies, except, unless used in nonsleeping staff and employee areas where the heating elements do not exceed 212 degrees Fahrenheit (100 degrees Celsius). 18.7.8, 19.7.8 This Standard is not met as evidenced by: 45508 Based on observation and interview the facility failed to prohibit the use of portable space heaters in the facility. This deficient practice increases the likelihood of fire cause by a heating device affecting all occupants. Facility census was 14 and licensed for 25. Observation on 4/7/2025 between 9:50 am and 10:49 am found portable space heaters in the following locations: 1. Billing Office 2. Imaging Office 3. Schedulers Office 4. Patient Access Office 5. Both Occupational Health Offices During interview on 4/7/2025 between 9:50 and 10:49 am staff confirmed the presence of the portable space heaters.”

“Electrical Systems - Essential Electric Syste CFR(s): NFPA 101 Electrical Systems - Essential Electric System Maintenance and Testing The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110. Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations. 6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70) This Standard is not met as evidenced by: 45508 Based on document review and interview the facility failed to maintain the emergency generator. This deficient practice increases the likelihood of generation equipment malfunction or failure and affects all occupants. Facility census was 14 and licensed for 25. Findings are: Document review on 4/7/2025 at 9:21 am found the facility could not provide documentation for monthly generator testing during the use of a temporary generator, nor an annual inspection or load bank test for the permanent generator. During interview on 4/7/2025 at 9:21 am staff confirmed the lack of documentation.”

“Electrical Equipment - Power Cords and Extens CFR(s): NFPA 101 Electrical Equipment - Power Cords and Extension Cords Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4. 10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5 This Standard is not met as evidenced by: 45508 Based on observation and interview the facility failed to prohibit the improper use of power strips and extension cords. This deficient practice increases the likelihood of electrical fire or injury and affects all occupants. Facility census was 14 and licensed for 25. Findings are: Observation on 4/7/2025 between 9:52 and 10:42 am found: 1. 3 way power tap in use in H.I.M. office 2. Daisy chained power strips and high draw appliances (refrigerator) in to power strips in the IT office. 3. Extension cord powering a lamp in the Quality Office 4. High Draw appliances (Toaster and Coffee Pot) into power strip in the Surgery Break Room During interview on 4/7/2025 between 9:52 and 10:42 am staff confirmed the inappropriate uses of power strips and extension cords.”

“42 CFR 485.623 The facility must meet the applicable provisions of the 2012 Edition of the Life Safety Code of the National Fire Protection Association. This facility is governed by Chapter 19, Existing Health Care Occupancies of the 2012 Edition of the National Fire Protection Association [NFPA], Chapter 101: Life Safety Code. Memorial Community Hospital received construction approval in 2003. The construction is classified as Type II (222) and includes two stories and a basement. Patients occupy the first and second floors only. Smoke barriers are located each floor. Smoke compartments are located as follows. First floor: Surgery wing, OR wing, Administrative wing, Kitchen wing, ER wing and Radiology wing. Second floor: North wing and South wing. Basement: Med Records wing, Boiler wing and Shell Space wing. There is a two hour fire/smoke barrier on the main level separating the Clinic area from the Health Care occupancy. The building is fully fire sprinkler protected and includes a fire alarm system with smoke detection in all corridors and spaces open to the corridors. The facility has a capacity of 21 and a census of 11 at the time of the survey. Memorial Community Hospital was found to be not in compliance with the requirements for participation in Medicare/Medicaid at 42 CFR 485.623, Life Safety from Fire, and the related National Fire Protection Association (NFPA) Standard 101 - 2012 edition.”

“Evacuation and Relocation Plan CFR(s): NFPA 101 Evacuation and Relocation Plan There is a written plan for the protection of all patients and for their evacuation in the event of an emergency. Employees are periodically instructed and kept informed with their duties under the plan, and a copy of the plan is readily available with telephone operator or with security. The plan addresses the basic response required of staff per 18/19.7.2.1.2 and provides for all of the fire safety plan components per 18/19.2.2. 18.7.1.1 through 18.7.1.3, 18.7.2.1.2, 18.7.2.2, 18.7.2.3, 19.7.1.1 through 19.7.1.3, 19.7.2.1.2, 19.7.2.2, 19.7.2.3 This Standard is not met as evidenced by: 45508 Based on document review and interview the facility failed to follow their fire response plan. This deficient practice increases the risk of injury to all occupants of the facility. The facility census was 11 and licensed for 21 at the time of survey. Findings are: Document review between 4/12/2024 at 9:00 am and 4/19/2024 at 11:00 am found the facility’s fire response policy required staff to make an announcement via the paging system of a fire and its location. Review of the Incident Report, authored by the facility, found that staff did not make the announcement described in the fire response policy and that corrective action was actively being taken. During interview on 4/12/2024 between 9:00 am and 10:30 am Staff identified there was a violation of policy, Staff had identified the cause of the policy noncompliance, and that they were actively taking corrective action at the time of survey.”

“Electrical Equipment - Testing and Maintenanc CFR(s): NFPA 101 Electrical Equipment - Testing and Maintenance Requirements The physical integrity, resistance, leakage current, and touch current tests for fixed and portable patient-care related electrical equipment (PCREE) is performed as required in 10.3. Testing intervals are established with policies and protocols. All PCREE used in patient care rooms is tested in accordance with 10.3.5.4 or 10.3.6 before being put into service and after any repair or modification. Any system consisting of several electrical appliances demonstrates compliance with NFPA 99 as a complete system. Service manuals, instructions, and procedures provided by the manufacturer include information as required by 10.5.3.1.1 and are considered in the development of a program for electrical equipment maintenance. Electrical equipment instructions and maintenance manuals are readily available, and safety labels and condensed operating instructions on the appliance are legible. A record of electrical equipment tests, repairs, and modifications is maintained for a period of time to demonstrate compliance in accordance with the facility’s policy. Personnel responsible for the testing, maintenance and use of electrical appliances receive continuous training. 10.3, 10.5.2.1, 10.5.2.1.2, 10.5.2.5, 10.5.3, 10.5.6, 10.5.8 This Standard is not met as evidenced by: 45508 Based on document review and interview the facility failed to inspect and test Patient Care Related Electrical Equipment (PCREE) as it entered the facility. This deficient practice resulted in a fire incident that affected 1 patient and had potential to affect all occupants of the facility. Facility census was 11 and licensed for 21 at the time of survey. Findings are: Document review between 4/12/2024 at 9:00 am and 4/19/2024 at 11:00 am found the facility did not have record of inspection/testing of the device when it entered the facility, nor any record of periodic testing of the device from any of the facilities it had reportedly been at. During interview between 4/12/2024 at 9:00 am and 4/19/2024 at 11:00 am Staff confirmed the lack of testing as the device entered the facility. Facility Staff, Staff at the facility the device originated from, and a manufacturers representative stated that there was no recent inspection/testing documentation as the device had been missing since at least December 2023.”